Nursing Professional Development Program: 2015/2016
Forms List
Form Identifier / Form Title / Page NumberForm A / Applicant Information / 2
Form B / Manager Approval / 3
Form C / Research Project Documentation / 4
Form D / Evidence Based Practice Project Documentation / 5
Form E / Quality Improvement Project Documentation / 6
Form F / Journal Club / 7
Form G / Conference Poster Presentation / 8
Form H / Conference Podium Presentation / 9
Form I / Primary/Secondary Grant Writer / 10
Form J / Enrolled in a BSN, MSN or DNP program / 11
Form K / MSN/DNP Credential / 12
Form L / Professional Nursing Organization Membership / 13
Form M / Professional Nursing Certification / 14
Form N / Publications / 15
Form O / Professional Award or Recognition / 16
Form P / Community Service Activity Participation / 17
Form Q / Community Service Activity Management / 18
Form R / Credentialed Medical Interpreter / 19
Form S / Teaching Classes with the Education Department / 20
Form T / Competency/Skills Validator / 21
Form U / Unit Councils / 22
Form V / Champion/SuperUsers / 23
Form W / E Learning Module Development / 24
Form X / Case Presentation / 25
Form Y / Skill Certifications (Non job requirement) / 26
Form Z / Instructor Status for KOH taught courses / 27
Form AA / CE Program Development / 28
Form BB / Patient Education Presentation / 29
Form CC / KOH Nursing Award / 30
Form DD / Professional Nursing Organization Officer or Committee Chairperson / 31
Form EE / KOH Division or Facility Committee / 32
Form FF / Increasing Patient Experience / 33
Form GG / Preceptor / 34
Form HH / Health Lifestyle and Work Environment / 35
Form A: Applicant Information
Name: ______
Last First Middle
Address: ______
Street
______
City State Zip
Work Email Address: ______
Phone: ______͏ Home ͏ Cell
Facility:______Employee ID number: ______
Unit Name: ______Unit Cost Center: ______Manager: ______
Highest Level of Nursing Education Completed: ͏ ADN/Diploma ͏ BSN ͏ MSN
Professional Certification (if applicable): ______
Certification and Certifying Organization
Nursing Professional Development Program Level: Check level of application
Clinical Professional Nurse:Level 1 / · Minimum1 year experience with KOH
· Completed Orientation
· BSN OR
· ADN/Diploma enrolled in BSN program OR
· ADN/ Diploma w/5 years of experience and certified in clinical specialty
· Score of “Meets Expectations” on current evaluation
· Evidence of 8 points
Clinical Nurse Leader:
Level 2 / · Minimum 2 years of staff RN experience
· Minimum of 6 months with KOH
· Completed Orientation
· BSN required
· Score of “Meets Expectations” on current evaluation
· Evidence of 11 points
Clinical Nurse Expert:
Level 3 / · Minimum 3 years of staff RN experience
· Minimum of 6 months with KOH
· Completed Orientation
· BSN required
· Professional Certification in Clinical Specialty
· Score of “Meets Expectations” on current evaluation
· Evidence of 13 points
Attach: Recent Picture
Form B: Manager Approval
Manager Name: ______
Facility: ______Unit: ______
I recommend ______as an applicant to the Kentucky One Health Nursing Professional Development Program.
Comments:
______
______
Manager Signature Date
Verification at time of Portfolio Submission: All of the above information is still correct.
______
Manager Initials Date
Form C:
Research Project Documentation
Name: ______Employee ID #: ______
Research Project Title:
______
Indicate your role in the project: ͏ Principle Investigator ͏ Co-Investigator
Type of research: ͏ Quantitative ͏ Quantitative ͏ Other
IRB approval: Name of IRB: ______IRB #: ______
Study Contributions: What specific work have you done on the project—i.e. literature review, data collection, IRB submission, subject recruitment, etc.
Date / Description of Activity / Hours______
Principle Investigator Signature Principle Investigator Name PRINTED
______
Date
Form D
Evidence Based Practice Project Documentation
Name: ______Employee ID #: ______
Evidence Based Practice Project Title: ______
______
What was the identified problem or opportunity: ______
______
PICOT question: ______
______
Type of project: ͏ Group Project ͏ Individual Project
If a group project, describe the applicant’s role in the project: (Examples conducted the literature review and analysis, collected the data, did the teaching, etc)______
______
______
EBP Practice Model Used: ͏ Iowa ͏ Johns Hopkins ͏ CHI ͏ Other
Literature Review: Please attach the literature review with a minimum of 5 recent references.
Describe the evidence based intervention: ______
______
______
______
Data/Outcomes: ______
______
______
Evaluation of the Project: ______
______
______
Manager/Project Sponsor Signature Manager/ Project Sponsor Name PRINTED
______
Date
Form E
Quality Improvement Project Documentation
Name: ______Employee ID #: ______
Quality Improvement Project Title: ______
______
What was the identified problem or opportunity: ______
______
Goal of the project: ______
______
Type of project: ͏ Group Project ͏ Individual Project
If a group project, describe the applicant’s role in the project: (Examples conducted the literature review and analysis, collected the data, did the teaching, etc)______
______
______
Change Model Used: ͏ PDCA ͏ Lewin ͏͏ Other
Describe the quality improvement intervention: ______
______
______
Data/Outcomes: ______
______
______
Evaluation of the Project: ______
______
Implications for Practice: ______
______
______
Manager/Project Sponsor Signature Manager/ Project Sponsor Name PRINTED
______
Date
Form F
Participation in an Approved KentuckyOne Health Journal Club
Facility: ______
Unit: ______
Chairperson/Leader: ______
Number of Journal Club meetings in the 12 months prior to portfolio completion: _____
Attach: One article review and critique presentation
I attest that the applicant ______has attended at least four journal club meetings in the previous 12 month period. Appropriate rosters or minutes verifying attendance can be provided if requested.
______
Manager/Chairperson Signature Manager/ Chairperson Sponsor Name PRINTED
______
Date
Form G
Conference Poster Presentation
Name of Conference: ______
______
Sponsor of Conference: ______
______
͏ Local/Regional ͏ National
Location of Conference: ______
Date of Conference: ______
Title of Poster Presentation: ______
______
Attach: Program agenda from conference listing poster and/or poster abstract
Attach: Poster (if possible) either picture of actual poster or Adobe computer copy
Form H
Conference Podium Presentation
Name of Conference: ______
______
Sponsor of Conference: ______
______
͏ Local/Regional ͏ National
Location of Conference: ______
Date of Conference: ______
Title of Presentation: ______
______
Length of Presentation: ______
Attach: Program agenda from conference listing presentation
Attach: Abstract for presentation
Form I
Primary/Secondary Grant Writer
Name of Grant: ______
Date of Grant application: ______
Project that the grant will support: ______
______
Was application successful? ______
͏ Primary writer ͏ Secondary writer
Attach: Verification page from grant application listing applicant as either primary or secondary grant investigator
Form J
Enrolled in a BSN, MSN or DNP Program
Name of Academic Institution: ______
Program of Study: ͏ BSN ͏ MSN ͏ DNP
Anticipated graduation date: ______
Attach: Current and most up to date transcript
Form K
MSN Credential/DNP Credential
Name of Academic Institution: ______
Course attendance years: ______
Course of study: ͏ MSN ͏ DNP
Date of graduation: ______
Attach: Transcript showing degree completion and/or copy of diploma
Form L
Membership in a Professional Nursing Organization
Name of Professional Organization:
1. ______
2. ______
Attach: Copy of membership wallet card or certificate with expiration date.
Form M
Professional Nursing Certification
Current area of clinical practice: ______
Certification1:
A. Credential: ______
B. Certifying Body: ______
C. Expiration: ______
Certification 2:
A. Credential: ______
B. Certifying Body: ______
C. Expiration: ______
Attach: Copy of certification wallet card or active certification credential with expiration date.
Notes:
Ø One certification must be applicable to current area of practice
Ø Certifications must be considered reimbursable as an eligible certification in KentuckyOne policy
Ø Professional certifications DO NOT include: AHA programs (ACLS/BLS/PALS) or other job required certifications such as NRP, STABLE or TNCC
Ø If you have questions regarding the eligibility of a particular certification for the NPDP, please consult with a board member or an educator
Ø Complete list of certifications is available at: http://insidekentuckyonehealth.org/Nursing/Professional-Development
Form N
Publications
Professional Nursing Publication: (Article) ͏ Regional ͏ National
Name of Nursing Journal: ______
Date of Publication: ______
͏ Primary Author ͏ One of group author
Professional Nursing Publication: (Article) ͏ Regional ͏ National
Name of Nursing Journal: ______
Date of Publication: ______
͏ Primary Author ͏ One of group author
Professional Nursing Publication: (Book Chapter)
Name of Nursing Book: ______
Title or Number of Chapter: ______
Date of Publication: ______
͏ Primary Author ͏ One of group author
Professional Nursing Publication: (Book)
Name of Nursing Book: ______
Title or Number of Chapter: ______
Date of Publication: ______
͏ Primary Author ͏ One of group author
Attach: (Article) Copy of the article with identifying journal information
Attach: (Book) Complete reference information in APA format
Form O
Professional Award or Recognition
Title of Award or Recognition: ______
______
Award Organization: ______
Date: ______
͏ Local/Regional ͏ National
Title of Award or Recognition: ______
______
Award Organization: ______
Date: ______
͏ Local/Regional ͏ National
Attach: Copy of written professional award or recognition
Form P
Participation in a Community Service Activity
Title of community service activity: ______
Name of organization:
______
Description of community service: ______
______
______
______
Date of Community Service: ______Hours worked: ______
______
Signature of Project Coordinator/Facilitator Name of Project Coordinator/Facilitator (Printed)
______
Date
Note: fundraisers, such as walks do not qualify in this category
Form Q
Development/Management of a Community Service Activity
Title of community service activity: ______
Name of organization:
______
Description of community service: ______
______
______
Describe your role in development/management of the community service activity:
______
______
Date of Community Service: ______Hours worked: ______
______
Signature of Project Coordinator/Facilitator Name of Project Coordinator/Facilitator (Printed)
______
Date
Note: fundraisers, such as walks do not qualify in this category
Form R
Credentialed Medical Interpreter
Language: ______
Attach: Certificate of completion of a formal medical interpreter training
Form S
Teaching Classes
Class Name: ______
Hours of Instruction: ______
Date/Time of Class: ______
CE Information (if applicable):
Ø CE number: ______# of CEs offered: ______
Ø CE provider: ______
______
Signature of Education Representative Name of Education Representative (Printed)
______
Date
Class Name: ______
Hours of Instruction: ______
Date/Time of Class: ______
CE Information (if applicable):
Ø CE number: ______# of CEs offered: ______
Ø CE provider: ______
______
Signature of Education Representative Name of Education Representative (Printed)
______
Date
Form T
Competency/Skills Validator
Facility: ______
Competency/Skill being validated / Date / Hours / Points______
Signature of Education Representative Name of Education Representative (Printed)
______
Date
Note: 1 point is given for each 4 hours of competency or skill validation up to a maximum of 2 points.
Form U
Unit Councils
Facility: ______Unit: ______
Name of Council: ______
Select one option: ͏ Chairperson/Co-Chairperson ͏ Participant/Member
Purpose of the Council: ______
______
How often does the council meet? ______
Applicant’s contributions to council activity: ______
______
______
______
I attest that the applicant ______has attended 75% of the council meetings in the previous 12 month period. Appropriate rosters or minutes verifying attendance can be provided if requested.
______
Manager/Chairperson Signature Manager/ Chairperson Sponsor Name PRINTED
______
Date
Form V
Champions/SuperUsers
Facility: ______Unit: ______
Champion or Superuser Project: ______
Purpose of Champion or SuperUser Designation: ______
______
______
Length of time in role: ______
I attest that the applicant ______has met the expectations of champion/superuser for ______at least a 6 month period.
______
Manager/Chairperson Signature Manager/ Chairperson Sponsor Name PRINTED
______
Date
Attach: One example of how you, as a champion/superuser, provided support to staff for the identified project. Include: your training responsibilities, dissemination of information, check off, etc. as appropriate.
Form W
E Learning Module
Facility: ______
Title of LEARN module: ______
Purpose of LEARN module: ______
______
Distribution group: ______
CE information (if applicable):
Ø CE number: ______# of CEs offered: ______
Ø CE provider: ______
______
Learn Administrator/Education Director Signature Learn Administrator/Education Director Name PRINTED
______
Date
Form X
Case Presentation
Facility: ______Unit: ______
Case Presentation Topic: ______
Date of Presentation: ______
Why was this case chosen for presentation: ______
______
______
Reference List: (Identify at least 3 references used to prepare for presentation
1. ______
2. ______
3. ______
Information Dissemination Method: ͏ Staff Meeting ͏ In-Service
͏ Poster ͏ LEARN module ͏ Other ______
______
Manager Signature Manager Name PRINTED
______
Date
Attach: Learning objectives, handouts, evaluation summation
Form Y
Skill Certifications (Non job requirement)
Facility: ______
Unit: ______
Certification being used for this skill point:
1. ______
2. ______
I attest that the certification listed above is not a job requirement on ______unit.
______
Manager/Chairperson Signature Manager/ Chairperson Sponsor Name PRINTED
______
Date
Attach: Copy of certification wallet card or active certification credential with expiration date.
Note: examples of this type of certification are: ACLS, PALS, NRP, Stroke, etc.
Form Z
Instructor Status
Facility: ______
Course for which you are an instructor:
1. ______
2. ______
I have fulfilled my minimum instructor obligations as required by the individual course and facility policy: ͏ Yes ͏ No
Number of Courses taught within the last year: